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Home My WebLink AboutBuilding Permit #547-15 - 30 PENNI LANE 12/15/2014TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received Permit NO. Date Issued:—Al/ rMP RTANT: Aimhcant must complete all items on this I Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes n Machine Shop Village yeso TYPE OF IMPROVEMENT PROPOSED USE Resiclefitial Non- Residential ❑ New Building ne family ❑ Addition ❑ Two or more family ❑ Industrial N 11 Atlon No. of units: ❑ Commercial r, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition _ ❑ Other 0 Septic'0 It :�Well'��Floodpla�n�Wet1ands'; .DWatsrshedD: t �1Water/Sewer'._ 4___�.. _nom Lt_a•___.------------ D C .TIO F WORTO BE PERFORMED: 1 OWNER: N, CONTR Address: Type or Print Uleariy) Supervisor's Construction LicenseL ��,q(6O Exp. Date: Home Improvement License: Za�3 —Exp. Date: 16r-" ARCHITECT/ENGINEER �-� - Phone: 7� Address: Reg. No FEE SCHEDULE: BULDING PERMIT: $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: W23 Receipt No.: , `;-3-2— NOTE: Persons contracting with unregistered contractors do not have access o the gu �anty fund Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Ad/Building n Or Decks Permit Application ❑ /Eertified Surveyed Plot Plan /Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ - Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products. OTE: All durnpster permits require sign off from Fire Department prior to issuance of Bldg Permit all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals iii the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording is be submitted with the building application Doc. Doc.Building permit Revised 2008mi Plans Submitted ❑ - Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Swimming Pools ❑ WeII ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION COMMENTS HEALTH r• i COkAMENTS k Reviewed on Signature Reviewed on Siqnature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comm Conservation Decision: Comments Water & Sewer Connection Siqnature S< Date Driveway Permit I)PW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft. ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No, MGL Chapter 166 Section 21A—F and G min.$10041000 fine n Doc:.Building Permit Revised 2008 Location 'S 6) ee N N' No.�! L'," -- Date l��) TOWN OF NORTH ANDOVER v Certificate of Occupancy $ Building/Frame Permit Fee $� -� Foundation Permit Fee $� Other Permit Fee $ TOTAL $ Check # 28352 Building Inspector O _ _ O O O O •� L CL d a C. ui ` ° o E c r a 0 CL v L Cc Cm ,� d O 1. y _-0 H d OEM -E"-o - `moz nc� — cnoo w. L cc 0 F— CL o= _ a L L cu -a CL x 1— p tq V m coLUW = -a— O O ti •y°) to = y '=+ W L— U Q 0-0 a�+r Cl) ) > c � o tIL Z CL 0 v Z U W F- CL Z w0 H U Cl) LLI —j a. Z �-: rm-7 H 0 cc z J Q W W CL W CL 0LU W 2 N Vf Z of Z U °C LL. Z OW. Q Z D z Z Z U W O Oui tG p� Ln m c E • m J W ti. -C c d W - +7 N TO N aiT O Z N a c to C — t M t an U — -C on O Q 7 00 C 0 =O i C i `1 O LL (n LL CC U LL �' LL d' N LL LL m N {n _ _ O O O O •� L CL d a C. ui ` ° o E c r a 0 CL v L Cc Cm ,� d O 1. y _-0 H d OEM -E"-o - `moz nc� — cnoo w. L cc 0 F— CL o= _ a L L cu -a CL x 1— p tq V m coLUW = -a— O O ti •y°) to = y '=+ W L— U Q 0-0 a�+r Cl) ) > c � o tIL Z CL 0 v Z U W F- CL Z w0 H U Cl) LLI —j a. Z �-: rm-7 Vroposal HIC #174377 I Z. Daimphousse�d e odfeng LLP A trusted name since 1938 Roofing - Siding - Windows 87 Belmont Street - North Andover, MA 01845 P: 978-683-4588 - F: 978-685-7446 NAME OF OWNER " '� fJ'�_• ADRESS OF I3 TEL. DATE:/ A We will remove all roof shingles off total roof area, up tom -layers. Replace any boards or sheathing at additional cost. A new 8" white aluminum drip edge applied on all edges. Approx. 6ft of ice and water membrane applied on eaves, 3ft in valleys, strips around skylights, along chimney flashing and sidewall junctions. Existing step flashings to remain. A new base sheet applied. A 3@1f architectural roof shingle installed. Install new vent pipe boot flashings. Waterproof existing chimney flashing and remove debris. Shingle Color: -�rICA arx/1/ fl /41,�'vL "qP Ridge Vent Upgrade Wood Sheathing Re air r ft. W - We Propose herby to furnish material and labor - complete in accordance with above specifications, Ptem of:� e c^dollars ($ Pa ment to be made as follows �k/ Authorized Signature NOTE: This proposal may b withdrawn by us .if not accepted with in) -4 days Acceptance of Proposal - The above prices, specifications and conditions are satisfactory and are herby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Signature Date of Acceptance: `� f Signature 5/7/2014 5:56:27 PM 8935 ® 02/02 ACORDIb CERTIFICATE OF LIABILITY INSURANCE k�t DATE(MMfDD/YYYY) 0 510 712 01 4 IRIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 00474 - 001 NAME: Doherty Insurance Agency Inc PO Box 1985 Andover, MA 01810 •(AIC. No. Ext): (978)415-0260 j>�ic. No.: EMAIL ADDRESS: GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS-MADE ❑ OCCUR INSURERS AFFORDING COVERAGE NAIC i INSURERA : A.I.M. Mutual Insurance Company 26158 INSURED Damphousse Roofing LLP INSURERS: DAMAGE TO RENTED $ PREMISES Ea occurrence MED EXP (Any one person) $ INSURER C : INSURERD : 87 Belmont Street North Andover, MA 01845 ENTL AGGREGATE LIMIT APPLIES PER: OLICY CT OC PRODUCTS- COMP/OP AGG $ IN URERE: INSURER F : AUTOMOBILE COVERAGE -5 CERTIFICATE NUMBER: REVISION NUMBER - THIS IS TOCERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ODL INSR UBR WVD POLICY NUMBER POLICY EFF MMlDDJYYW POLICY EXP MIDDIYYYY LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS-MADE ❑ OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED $ PREMISES Ea occurrence MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ ENTL AGGREGATE LIMIT APPLIES PER: OLICY CT OC PRODUCTS- COMP/OP AGG $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED r SCHEDULED AUTOS AUTOS HIREDAUTOS NON -OWNED AUTOS COMBINED SINGLE LIMB $ Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ A WORK ND EMPLOYERSELIABI LIABILITY ANY T� PRIET�R/PgqRRTNER/FXECUTIVE Y / N OFFICER/IdEMBER EXCLU , � (Mandatory in NH) If yes, de 9rON OF OPERATIONS below NIA AWC400-7028774-2014A 4/17/2014 4/17/2015 yyC 5 TP X TORY LIIMiUTS ER E.L. EACH ACCIDENT $ 500,000.0w -- E.L. DISEASE - EA EMPLOYEE $ 500,000,00 E.L. DISEASE - POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS 1 LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) No partners are covered by the workers compensation policy. Town of North Andover 1600 Osgood Street North Andover, MA 01845 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE f _ S ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD 9315 Cliant8! i&Q15 nAMPHnUSSF ACORD,� ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR CERTIFICATE OF LIABILITY INSURANCE oM7M aYYY' PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Doherty Insurance Agency, Inc. P.O. Box 1985 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 21 Elm Street PIRATION am (11111111110IMM 04112115 Andover, MA 01810 INSURERS AFFORDING COVERAGE NAIC 8 INSURED INSURER A: Atain Specialty Insurance Comps Damphousse Roofing LLP 87 Belmont St North Andover, MA 01845 INSURER B: INSURER c: INSURER D: INSURER E: OAhUUGE TO RENTEO $100,000 COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSRI TYPE OF INSURANCE GENERAL LIABILITY POLICY NUMBERFO CIP16938701 04112114 PIRATION am (11111111110IMM 04112115 LIMITS A EACH OCCURRENCE S1 000 000 X COMMERCIAL GENERALLIA8ILITY OAhUUGE TO RENTEO $100,000 CLAIMS MAGE 51OCCUR MED EXP (Arty one pemon) S5.000 PERSONAL 6 ADV INJURY S1 000 000 X GENERAL AGGREGATE S2 000 000 GENt AGGREGATE LIMIT APPLIES PER: PRODUCTS - OOMPIOP AGG s2=.000 X1 POLICY PRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea eco") $ BODILY INJURY ALL OWNED AUTOS SCHEDULED AUTOS (Per Person) S BODILYIWURY E HIRED AUTOS NON -OWNED AUTOS (Per acadom) PROPERTY DAMAGE S (Paracoaem) GARAGE LIASILITV AUTO ONLY - EA ACCIDENT S OTHERTHAN EAACC S ANYAUTO AUTO ONLY: AGG $ EXCES&UMBRELLA LIABILITY EACH OCCURRENCE $ AGGREGATE S OCCUR FICLAIMS MADE S S DEDUCTIBLE S RETENTION S WORKERS COMPENSATION AND ViC STATU OTH EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNEREXECUTIVE E L. EACH ACCIDENT E E.L DISEASE- EA EMPLOYEE S OFFICERIMEMBER EXCLUDED? It yes. desatae wider SPECIAL PROVISIONS baba E.L. DISEASE . POLICY LIMIT S OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Covering operations usual to Damphousse Roofing LLP... Town of North Andover 1600 Osgood Street North Andover, MA 01845 i ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION IEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL --12_ DAYS WRITTEN TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAILURE TO 00 $O SHALL NO OBLIGATION OR UA13UM OF ANY KIND UPON THE INSURER, ITS AGENTS OR AUTHORIZED ACORD 2542001M) 1 of 2 NS3046611M30465 / DML ( ) 0 ACORD CORPORATION 1988 vvwLrwvvwr.09 G iW 4 tvwtuuzl S -W uOeJa43 pelsli sePIod 841 Aq pepJoiia 06MA00 041 Jeile Jo pusixe 'puewe IlleApflsu Jo AleAlleunlye 1! s0op Jou 'Jeploy eleoliliJeo eyl pue 'Jeonpoid Jo eAlleluesaJdej pazpo4lne '(s)JeJnsui 6ulnssl 041 ue0A40q 138JI000 E elnlllsuoa loU sa0p wJoi SI41 to epls esJenaJ 041 uo souemsul io aieay!POO 041 H3WIVIOSia •(s)luawessopus tans io nail ul Jeploy aleommeo eta of si46li Jeiuoo iou seop eieoN!ueo sl41 uo lueweleis V •iuewesJopus ue eJlnbeJ flew selollod ulepoo lAollod ayi io suop puoo pue suual eyl of laa!gns `a3AIVM SI NOIIVJOliens it (s)luewesJopue yaps io Hell ul Deploy eleolilveo e4i of siy6p Jeiuoo lou seop elealNiJaa sl41 uo lueweieis y •pewopus eq isnw (sel)Aollod e4i 'a3unSNl iVNOWaaV ue sI Jeplo4 alealiluaa 041 it 1NVIHOdWI y% Massachusetts - Departnnen? Of ?U4alic Safe_y �--� Board Of Building !Regulations and StanCaros Con%tructinn Supervisor License: CS -067560 SHAUN M TWOMEY ' �= 61 PATROIT ST : N ANDOVER MA 01845 irr tssora; 10125/2015 _.�_. CS -055108 DOUGLA-S i LEGARE 79 GARY .1 -T ` ,4w—Rdmi. -+1-LA 01830 �,-- 09102J2014 Office of Consumer Affairs & Business Re:utation �OME IMPROVEMENT CONTRACTOR °`Registration: 174377 Type: :Expiration_ 2/412015 LLP DAIViPHOUSSE ROOFING LLP SHAUN R;VON41rY 87 SEL MON-- ST N. ANDOVER, NINA 01845 °— Undersccretarc The Commonwealth ofMassachusetts Department of IndustrlqlAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name Address: 06 ld/-' /////. Phone #: Are you an employer? Check the appropriate box: 1. Pam a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] `f7Y-k/ Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Pl bing repairs or additions 12. oofrepairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 7 Homeowners who submit this affidavit indicating they ace doing all work and then hire outside contractors must submit anew affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. _ �— Insurance Company Name,� ,�L , Policy # or Self -ins. Lic. #;, j�� " L 7 �` % �7�Expiration Date: /45 Job Site Address: ,City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certifokunder thepains andpenalties ofperjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, • express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please -be sure that the affidavit is -complete and printed legibly. The Department has provided a space -at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth ofMlassachusetis Department of Industrial Accidents Office of Investigations 600 'Washington Street Boston, MA. 02111 Tel, # 617-72.7-4900 est 406 or 1-877�,MASSAFB Revised 5-26-05 Faze # 617-727-7749 www.znass,govldza